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A publication of Texas Children’s Health Plan PROVIDER NEWS FALL 2 01 4 IN THIS ISSUE 2 Medical Director Corner 3 Synagis season 2014 to 2015 5 OB Provider Incentive Program 8 Prepare for cold and flu season 4 Lab provider changes 6 ECI Services 10 Short acting BETA agonists 11 CONNECT Program 12 CMS NCCI and MUE guidelines ND-1014-210 P.O. Box 301011, NB 8301 Houston, Texas 77230 NONPROFIT ORG. U.S. POSTAGE PAID PERMIT NO. 4 HOUSTON, TX MEDICAL DIRECTOR CORNER Vice President and Chief Medical Officer Angelo P. Giardino, MD, PhD of their patients diagnosed with sinusitis, 60 percent with pharyngitis, and 70 percent with bronchitis in children ages 6 and under. The total number of prescriptions for amoxicillin being given to children 6 and under is 65 percent of all amoxicillin claims. Choose Wisely: An initiative of the ABIM Foundation A s we enter into the fall respiratory season, the American Academy of Pediatrics (AAP) and Texas Children’s Health Plan are requesting for our providers to “choose wisely” when considering antibiotics and cough and cold medicines. Texas Children’s Health Plan has analyzed data from our providers as it relates to the top two recommendations focusing on (1) antibiotics should not be used for apparent viral respiratory illnesses, and (2) cough and cold medicines should not be prescribed or recommended for respiratory illnesses in children under 6 years of age. In the first recommendation from AAP, antibiotics should not be used for apparent viral respiratory illnesses including sinusitis, pharyngitis, and bronchitis. Although overall antibiotic prescription rates for children have fallen, they still remain alarmingly high. Data from September 2013 through March 2014 on the most prescribed antibiotic shows that our providers are prescribing amoxicillin to 50 percent 2 TexasChildrensHealthPlan.org Unnecessary medication use for viral respiratory illnesses can lead to antibiotic resistance and contributes to higher health care costs and the risks of adverse events. Antibiotics are effective against bacterial infections, certain fungal infections, and some kinds of parasites. Antibiotics don’t work against viruses. Symptom relief might be the best treatment option for infections caused by viruses like colds, most sore throats, bronchitis, and some ear infections. Other consequences of antibiotic resistance are the increased costs associated with prolonged illnesses, including expenses for additional tests, treatments and hospitalization, and indirect costs, such as lost income. The CDC has a Get Smart campaign on the principles for appropriate antibiotic use for pediatric upper respiratory tract infections. These guidelines were developed in collaboration with the American Academy of Pediatrics and members of the American Academy of Family Physicians. The CDC then collaborated with members of the American Academy of Family Physicians, American College of Physicians, Infectious Diseases Society of America, and the American College of Emergency Physicians. The pediatric guidelines provide a definition of appropriate 832-828-1008 1-800-731-8527 prescribing and include the following practical tips when parents ask for antibiotics to treat viral infections: Explain that unnecessary antibiotics can be harmful. Tell parents that based on the latest evidence, unnecessary antibiotics CAN be harmful, by promoting resistant organisms in their child and the community. Please see Dr. Peacock’s article on page 9 as well. Share the facts. • Explain that bacterial infections can be cured by antibiotics, but viral infections never are. • Explain that treating viral infections with antibiotics to prevent bacterial infections does not work. Build cooperation and trust. • Convey a sense of partnership and don’t dismiss the illness as “only a viral infection.” • Encourage active management of the illness. • Explicitly plan treatment of symptoms with parents. Describe the expected normal time course of the illness and tell parents to come back if the symptoms persist or worsen. Be confident with the recommendation to use alternative treatments. • Prescribe analgesics and decongestants, if appropriate. • Emphasize the importance of adequate nutrition and hydration. • Consider providing “care packages” with non-antibiotic therapies. • Create an office environment to promote the reduction of antibiotic use. Talk about antibiotic use at 4- and 12-month wellchild visits. By sharing these tips not only are you “choosing wisely,” you will strengthen your relationship with your patients and avoid antibiotic resistance. In the second recommendation from AAP, cough and cold medicines should not be prescribed or recommended for respiratory illnesses in children under 6 years of age. No one likes getting a cold, but a child’s cold can be hard on the child as well as their parents. Children get 6 to 8 colds per year that typically last 3 to 14 days. Wellmeaning parents who want to help their sick child will often ask a provider for prescription cold or cough medicine. Cough and cold medicines are the best way to help a child who has a cold feel better—right? Think again. Cough and cold medicines aren’t recommended for children younger than age 2, and the jury is still out on whether cough and cold medicines are appropriate for older kids. So how can you treat a child’s cold? Cough and cold medicines don’t effectively treat the underlying cause of a child’s cold, and they won’t cure a child’s cold or make it go away any sooner. These medications also have potentially serious side effects, including rapid heart rate and convulsions. The Food and Drug Administration (FDA) discourages the use of cough and cold medicines for children younger than age 2. Many cough and cold products for children have more than one ingredient, increasing the chance of accidental overdose if combined with another product. Using claims and pharmacy data from September 2013 through March 2014, the results show that our providers are prescribing cough medicine at a high rate to children who are 6 and under. In fact, in this time period the health plan reports that Bromfed DM was the most prescribed cough medicine. Furthermore, in the graph below, there is an alarming prescription rate of 63 percent for Bromfed DM for children ages 6 and under. The highest diagnosis for this prescription is otitis media and the second most prescribed diagnosis is strep throat. Bromfed DM has not been shown to cure otitis media nor strep throat. Likewise, cough and cold products have not been shown to be safe or effective in children younger than 6 years of age. Bromfed DM has significant side effects including headaches, dizziness, and nausea. Moreover, it costs the health plan millions of dollars. Providers are encouraged to talk to patients and their caregivers about non-prescriptive alternatives that will relieve the symptoms of these diagnoses. We hope that you implement the Choosing Wisely® recommendations into your practice. Synagis season 2014 to 2015 Texas Children’s Health Plan will authorize the usage of Synagis for those infants requiring the vaccine beginning with dates of service October 1, 2014 to February 28, 2015. Texas Children’s Health Plan will again require a prior authorization for this drug that providers can obtain by using the form available at navitus. com/texas-medicaid-star-chip/priorauthorization-forms.aspx. This form will include the most current guidelines for use and include the specialty pharmacies from which the drug can be ordered and shipped. And like last year, this medication is available only from select specialty pharmacies Maxor Pharmacy and Avella Pharmacy. Providers can fax their authorization form to either of these pharmacies and they will work to obtain the needed authorization. PLEASE CHECK with your Provider Relations Manager for more information as the season for vaccinating our population nears. 1-800-731-8527 832-828-1008 TexasChildrensHealthPlan.org 3 Laboratory provider changes effective January 1 T exas Children’s Health Plan has entered into an agreement with Quest Diagnostics to serve as our exclusive reference lab provider effective January 1, 2015. In the interim, Quest will serve as our Preferred Reference Lab and we request that you begin utilizing Quest Diagnostics as much as possible for your reference lab needs. Per state regulations, laboratory specimens that are required to be sent to state laboratories for processing will continue to follow guidelines provided in the Texas Medicaid Provider Procedures Manual (TMPPM). If you do not currently have a relationship with Quest Diagnostics, you will be contacted by a Texas Children’s Health Plan or Quest Diagnostics representative to discuss how to establish a relationship with Quest. Providers currently have two options for accessing reference laboratory services. These options will continue and, after January 1, 2015, should be directed to Quest Diagnostics as indicated below: 1. Provider can collect specimens in office and Quest will pick up specimens for testing. 2. Texas Children’s Health Plan members can be sent to Quest Patient Service Centers for specimen collection and testing. Providers may continue to perform specific lab tests in their office and receive reimbursement fromTexas Children’s Health Plan. Effective January 1, 2015, the attached list of Physician Office Lab Tests are reimbursable by Texas Children’s Health Plan. All other lab tests must be referred to Quest Diagnostics or State of Texas Laboratories as required in TMPPM. We sincerely appreciate the care and service you provide to our members. For questions, please contact Provider Relations at 832-828-1008 or toll-free at 1-800-731-8527. Physician Office Lab Test List 80061 81000 81001 81002 81003 81005 81007 81025 82009 82044 82120 82247 82270 82465 82731 82947 82948 82950 82962 83036 83037 83655 84112 84450 84460 4 Lipid Panel (80061) Urinls Dip Stick/Tablet Reagnt Non-Auto Micrscpy (81000) Urinalysis with Microscopy, Automated Urnls Dip Stick/Tablet Rgnt Non-Auto W/O Micrscp (81002) Urinalysis w/o Microscopy, Automated. Urinalysis, Qualitative Urine Screen for Bacteria Urine Pregnancy Test Visual Color Cmprsn Meths (81025) Acetone or Other Ketone Bodies Urine Dipstick For Micro-Albumin Amines Vaginal Fluid Qualitative (82120) Bilirubin Total (82247) Blood Occult Peroxidase Actv Qual Feces 1 Deter (82270) Cholesterol Serum/Whole Blood Total (82465) Ftl Fibronectin Cervicovag Secretions Semi-Quan (82731) Glucose Quantitative Blood Xcpt Reagent Strip (82947) Glucose, Blood Reagent Strip Glucose Post Glucose Dose (82950) Glucose Blood Test Hemoglobin A1C Hemoglobin A1C Lead Screening Aminsure Transferase Aspartate Amino Ast Sgot (84450) Transferase Alanine Amino Alt Sgpt (84460) TexasChildrensHealthPlan.org 832-828-1008 84703 85007 85013 85014 85018 85025 85027 85048 85610 85651 86308 86403 86580 87081 87210 87220 87420 87430 87800 87804 87807 87880 88720 89060 1-800-731-8527 Chorionic Gonadotropin Assay Blood Count Smear Mcrscp w/Mnl Difrntl WBC Count (85007) Spun Hematocrit Blood Count Hematocrit (85014) Blood Count Hemoglobin (85018) Blood Count Complete Auto&Auto Difrntl WBC Count (85025) Blood Count Complete Automated (85027) WBC Prothrombin Time Sedimentation Rate Heterophile Antibodies Screen (86308) Particle Agglutination (Rapid Strep) TB (Intradermal & Tine) Cul Prsmptv Pthgnc Organism Scrn W/Colony Estimj (87081) Smr Prim Src Wet Mount Nfct Agt (87210) Koh—Tissue Exam For Fungi Iaad Eia Respiratory Synctial Virus (87420) Strep Screen Iadna Multiple Organisms Direct Probe Tq (87800) Iaadiadoo Influenza (87804) Iaadiadoo Respiratory Synctial Virus (87807) Iaadiadoo Streptococcus Group A (87880) Bilirubin Total Transcutaneous (88720) Crystal Id Light Microscopy Alys Tiss/Any Fluid (89060) OB Provider Incentive Program Texas Children’s Health Plan offers an OB Provider Incentive Program to reward your group for providing quality care to our members during their pregnancy, from early prenatal care to delivery and postpartum care. The first payout was August 2014 for the look back period from November to April 2014. Qualifying measure #1 Qualifying measure #2 Retention Measures Retention is defined as the number of pregnant women who stay enrolled in Texas Children’s Health Plan through their delivery. Your retention rate is represented as a percentage of the total pregnant women who are assigned to your OB Group. You meet the retention threshold if your retention rate is 70 percent or greater. (i.e., At least 70 percent of potential deliveries are still Texas Children’s Health Plan members at the time of delivery.) *Maternal Fetal Medicine Specialists (MFM) are exempt from the volume measure. Performance measure #1 Performance measure #2 How the program works: The OB Incentive Program has 4 parts: 2 qualifying measures and 2 performance measures. All payouts are biannual. To be eligible to receive the biannual payments, you must meet the 2 qualifying measures, which focus on volume and member retention. The program’s primary goal is to encourage you to provide quality care to Texas Children’s Health Plan pregnant members. In order to receive the biannual payments, you must meet at least one of the performance measures, which emphasize early prenatal and postpartum care. You will be paid for each goal that you exceed. How to qualify: You qualify for the OB Incentive Program by meeting both of the qualifying measures below. Volume Measure* Volume is the number of deliveries where the obstetrician’s group is the primary care provider of obstetrical care. You meet the volume threshold if you serve as the primary obstetrical provider for a minimum of 50 deliveries for Texas Children’s Health Plan members per group, per year. Payout schedule We calculate qualifying measures once a year based on the calendar year. After meeting both qualifying measures, you are then eligible to receive payment for one or both of the following performance measures. 1. Prenatal Care Prenatal visits performed within 42 days of a member’s enrollment in Texas Children’s Health Plan. 2. Postpartum Care Postpartum visits performed between 21 to 56 days after delivery. 3. Payout Schedule See chart below. Payment administration • Payment will be made to the Vendor and Vendor Tax ID number to which the practice (and the Practice’s providers) is affiliated for claims payment. We will not pay individual physicians if their claims payments are affiliated with a group. • Provider groups must be actively contracted with CHIP and STAR (not retired or terminated) at the time of payout to be eligible for payment. • Explanation of Payment (EOP) statements will be prepared on a biannual basis to distribute to each practice. Payments are consolidated for multiple practices and providers who practice within the same vendor and tax ID number. We cannot direct how the Vendor distributes money within its practice. • We will communicate the performance and payout results to the practice. The individual OB scores will be attached to the EOP. Program changes and continuation • Texas Children’s Health Plan reserves the right to continue and/or modify the program but attempts to provide advance notice of any changes that would be significant to a provider. • Providers or practices under Texas Children’s Health Plan payment review at the time of payout will not be eligible for OB Incentive payout and will remain ineligible until removed from payment review. Payment frequency Measurement period for payment #1 Payout #1 Measurement period for payment #2 Payment #2 Biannual payments with qualifying measures calculated once a year November 2013 to April 2014 August 2014 May 2014 to October 2014 February 2015 Note: Provider group must be actively contracted with Texas Children’s Health Plan for CHIP and STAR at the time of payment to be eligible. 1-800-731-8527 832-828-1008 TexasChildrensHealthPlan.org 5 Early Childhood Intervention services and referrals 7 calendar days from the day the provider identifies the member. Claims for all physical, occupational, speech and language therapy must be submitted to Texas Children’s Health Plan from the ECI Provider. To find a program in your area and make a referral: E arly Childhood Intervention (ECI) is a statewide program combining case management and service coordination for children from birth to age 3 who have disabilities or developmental delays. ECI teaches families how to help children reach their maximum potential through education and therapy services. Federal law requires that providers refer children to ECI within 2 working days of identifying a developmental disability or delay. Providers can call the ECI Referral Line at 1-800-628-5115 to identify an ECI program in the member’s area. Brochures and posters are available for provider offices by calling Texas Children’s Health Plan Provider and Care Coordination. Members can self-refer to local ECI service providers without a referral from the member’s PCP. A diagnosis is not required prior to referring a member to ECI. Infants and toddlers from birth to age 3 may be referred if: • Services are personalized for each child and family. • Involves families in services that incorporate therapeutic intervention strategies in their child’s daily routine. • An interdisciplinary team of licensed or credentialed professionals are available for the treatment of each child. • Call DARS Inquiries Line at 1-800-628-5115. • Visit dars.state.tx.us/ecis/searchprogram.asp to find a local program in your area. • Contact your local ECI program with information on the child in need. • Provide the contact information to the family so they can contact ECI directly. • Incorporates measurable outcomes. Texas Children’s Health Plan has only qualified ECI providers in network for members under the age of 3. Visit TexasChildrensHealthPlan.org to search for ECI providers in your area. • Offers services in the home and community setting. (Source: Department of Assistive and Rehabilitative • Every family received case management. Services Division for Early Childhood Intervention Services, dars.state.tx.us/ecis.) • Guides families in transitioning to different services after the child is 3 years old. • Developmental delay • The family suspects delays in one or more areas of development. • Medically diagnosed condition • Auditory or visual impairment • The child exhibits atypical developmental delay. Steps for determining ECI services: Local programs conduct free developmental screenings and assess the child for developmental delay and eligibility. Once a child is accepted and enrolled, an Individual Family Service Plan (IFSP) is developed and services are initiated. Texas Children’s Health Plan will accept and coordinate services indicated in an IFSP, including claims payment for PT/OT/ST. If the child is not accepted in the program, ECI staff will refer the family to other resources. ECI has provided specialized services for more than 30 years at no cost to the family. These services range from therapy to nutrition counseling for Texas families with children who have developmental delays and disabilities. This makes ECI a great resource for members who qualify needing speech therapy services. These services are provided by a Licensed Speech Language Pathologist. TexasChildrensHealthPlan.org • Specialize in infants and toddlers. The following categories are evaluated to determine eligibility: • They have medical conditions known to result in delays in development. 6 Benefits of ECI services: 1 Referral. 2 Evaluation with interdisciplinary team to determine child’s eligibility. 3 Once it is determined the child is eligible for services, the interdisciplinary team and parents work together to develop an Individualized Family Service Plan (IFSP). 4 The IFSP is shared with the child’s physician with parental consent. Texas Children’s Health Plan ensures network providers are knowledgeable about the federal laws on the referral procedures with ECI. Network providers are required to identify and provide referral information to the LAR of any member under the age of 3 who is suspected of having a developmental delay or otherwise meeting eligibility criteria for ECI services within 832-828-1008 1-800-731-8527 Reimbursement code for sports and camp physicals As a value added service to our CHIP and STAR members, Texas Children’s Health Plan will reimburse code 97005 – Athletic Training Evaluation and Management. This code is only reimbursed for sports and camp physicals. Payment for this service will be a flat rate of $30 for participating providers only. Texas Children’s Health Plan will pay for 97005 – Athletic Training Evaluation and Management on the same date of service a Texas Health Steps (THSteps) visit occurs. If you need further clarification, please contact your Provider Relations Manager at 832-828-1008 or 1-800-731-8527. Medical record documentation Correct Texas Health Steps requirements billing with rendering provider A s the patient’s medical home, primary care physicians are required to maintain comprehensive and accurate medical records to ensure quality and continuity of care. The record must support medical necessity based on the clinical condition and needs of the patient as well as the specific elements required to satisfy the level or type of service described in the Current Procedural Terminology (CPT) edition. Providers billing for Texas Health Steps: Please include the attested NPI number of the rendering individual provider in box 24J on paper claims or loop 2310B on EDI claims when using a group NPI number as the billing NPI. Providers who render a service and bill with an individual provider NPI number do not need to add the information in the rendering provider field. Please follow this guide for Texas Health Steps claims: Billing NPI Rendering NPI Individual provider Not needed if same individual Group NPI Must be NPI of individual rendering service Using an attested NPI number as required by the State of Texas allows Texas Children’s Health Plan to submit the claim to the State of Texas encounter system, which allows the State to track member usage and provides data on provider utilization. If you have questions, please call your Texas Children’s Health Plan Provider Relations team at 832-828-1008 or toll-free 1-800-731-8527. Retrospective reviews are routinely performed by state agencies and Texas Children’s Health Plan to ensure the medical record documentation supports the services that were billed. In the event the documentation does not support the services billed, the claims are subject to recoupment. With the implementation of ICD-10 approaching rapidly, it is very important for each provider practice to perform a self-evaluation to ensure services rendered are being documented appropriately in the medical record. It is important to provide complete diagnosis coding that includes the underlying conditions so that acuity can be appropriately measured. The medical record documentation should include the specificity needed to support payment of the ICD-10 codes. Following is a list of items that should be documented in the medical record for all providers: • Patient identification information (full name, address, phone number). • Patient’s history (history of present illness, past history, family history, social history). • Present physiological condition (drug or allergy sensitivities, current medications). • Progress notes: ˚ P atient’s complaint or reason for visit ˚ R esults of physical examinations ˚ T ests, procedures, and medications ordered by physician ˚ Diagnosis and problems identified ˚ H ealth education/preventative services performed ˚ L aboratory, referral, and consultation notes/reports ˚ C opies of reports concerning hospital admissions (including authorizations, surgical reports, and discharge summaries) • Centralized vaccine tracking log: ˚ Vaccine given ˚ Vaccination date (month, day, year) ˚ Vaccine lot number ˚ Name of vaccine manufacturer ˚ Signature and title of the health-care provider administering the vaccine ˚ Organization name and address of the clinic location (where the records are kept) ˚ Date on Vaccine Information Statement issued to patient, parent, or guardian • Documentation that supports that the member was notified of all abnormal laboratory and/or diagnostic results. • Documentation of instructions and education provided to the member for interventions that occurred during office visits. • Documentation of provider-to-provider communications. Additional Mandatory Requirements (2013 Texas Medicaid Provider Procedures Manual – Section 1: Provider Enrollment, Section 1.6.10) • All entries must be legible, dated, and signed by the performing provider. • Each page of the medical record should include the patient’s name and Texas Medicaid number. • Prior authorizations should be included, if applicable. • Medically necessary diagnostic lab and X-ray results are included in the record, and abnormal findings should have an explicit notation of the follow-up plans. • Prior authorizations should be included, if applicable. • Unresolved problems should be noted in the record. •A llergies and adverse reactions (including immunization reactions) must be prominently noted in record. 1-800-731-8527 832-828-1008 TexasChildrensHealthPlan.org 7 Prepare your patients for cold and flu season Harold J. Farber, MD, MSPH, FAAP, FCCP Associate Professor of Pediatrics, Pulmonary Section Baylor College of Medicine, Texas Children’s Hospital Associate Medical Director, Texas Children’s Health Plan > WHAT SORT OF FLU SEASON IS EXPECTED THIS YEAR? Getting through the high demand of cold and flu season can be challenging. Here are a few things to think about to help parents manage a mild illness at home. • Give them a prescription for a pain and fever reliever to have on hand at home. Acetaminophen is on the Texas Medicaid Preferred Drug list and can be covered with a physician’s prescription. Be sure to include a weight-based dose (concentration of pediatric acetaminophen is 160mg/ml) and encourage parents to use a measured dosing device. • Give parents of infants a bulb syringe and prescription for saline nose drops to keep their child’s nose clean and make their breathing easier. Nasal irrigation with saline can help alleviate a sore throat, thin nasal secretions, and improve nasal breathing in older children as well, reducing the need for further medication. Saline nose drops are on the Preferred Drug List and can be covered with a physician’s prescription. • Honey has been shown to help a cough from a cold. Recommend that parents administer ½ to 1 tsp. of undiluted honey just before bedtime. Honey should not be given to children younger than 1 year of age because of concerns about infant botulism. Cough medicines are of no more benefit than a placebo. The American Academy of Pediatrics Red Book discourages the use of cough and cold medicine for children under 6 years of age because of lack of efficacy and concerns regarding safety. • Before parents ask for antibiotics, explain that unnecessary antibiotics can be harmful and colds are not cured by antibiotics. Be sure to provide an active treatment plan to parents that includes the treatment strategies already mentioned. • Smoke exposure makes colds worse. Help your tobacco dependent caregivers by giving them a referral to the National Smoker’s Helpline at 1-800-QUIT NOW (1-800-784-8669). • Be sure that your patients over 6 months of age get the influenza vaccine. Although we can’t prevent all respiratory viral infections, this is one very important one that we can help to prevent. Inactivated and live attenuated influenza vaccine can be given simultaneously with other live and inactivated vaccines. • Inactivated influenza vaccine is well tolerated by nearly all egg allergic patients. The AAP Red Book advises that children with a history of mild reactions to egg (such as hives alone) can receive inactive influenza vaccine in the physician’s office. Watch the patient in the office for 30 minutes after immunization. Children with a history of severe reaction to eggs should consult with an allergist prior to influenza vaccination. Patient Information sheets on cough and cold care are available from your Texas Children’s Health Plan Provider Relations representative. 8 TexasChildrensHealthPlan.org 832-828-1008 CDC update on this year’s influenza season 1-800-731-8527 It’s not possible to predict what this flu season will be like. Flu seasons are unpredictable. While flu spreads every year, the timing, severity, and length of the season varies from one year to another. > WILL NEW FLU VIRUSES CIRCULATE THIS SEASON? Flu viruses are constantly changing so it’s not unusual for new flu viruses to appear each year. For more information about how flu viruses change, visit cdc.gov/flu. > WHEN WILL FLU ACTIVITY BEGIN? The timing of flu is very unpredictable and can vary from season to season. Flu activity most commonly peaks in the U.S. in January or February. Seasonal flu activity can begin as early as October and continue as late as May. > WHAT SHOULD YOU DO TO PREPARE PATIENTS FOR THIS FLU SEASON? CDC recommends a yearly flu vaccine for everyone 6 months of age and older as the first and most important step in protecting against this serious disease. While there are many different flu viruses, the seasonal flu vaccine is designed to protect against the top 3 or 4 flu viruses that research indicates will cause the most illness during the flu season. > WHEN SHOULD PATIENTS GET VACCINATED? Doctors and nurses are encouraged to begin vaccinating their patients soon after the vaccine becomes available. Those children ages 6 months through 8 years who need two doses of vaccine should receive the first dose as soon as possible to allow time to get the second dose before the start of flu season. The two doses should be given at least 4 weeks apart. It takes about 2 weeks after vaccination for antibodies to develop in the body and provide protection against the flu. Summary of the AAP Clinical 2013 Report: Principles of Judicious Antibiotic Use Cynthia Peacock, MD Associate Medical Director, Texas Children’s Health Plan S imilar to the CDC recommended use of antibiotics for viral infections, the AAP clinical report addresses the three most common bacterial URIs—acute otitis media, acute bacterial sinusitis, and group A streptococcal (GAS) pharyngitis—and guides treatment. Acute Otitis Media is defined as middle ear effusion with signs of inflammation (e.g., bulging). Watchful waiting without antibiotics should be considered for children older than 2 years of age who have unilateral disease without severe symptoms. Amoxicillin remains the first-line therapy and the use of amoxicillin with clavulanate if amoxicillin was used in the prior 6 weeks or if a high local prevalence of amoxicillin-resistant Haemophilus influenza is confirmed. Acute Bacterial Sinusitis antibiotic treatment should be reserved for severe disease with high fever and purulent rhinorrhea or persistent rhinorrhea and cough without improvement 10 days into the course and situations where clinical worsening follows initial improvement in URI symptoms. Practitioners should not consider azithromycin for treatment of acute otitis media or acute bacterial sinusitis because of the high rates of resistance for pneumococcus, the most common etiologic agent. The GAS Pharyngitis recommendation includes always testing and confirming before prescribing an antibiotic and testing only when 2 of the following are present: fever, tonsillar exudates/swelling, swollen/ tender anterior cervical nodes, and absence of cough. Testing generally is not recommended for those younger than 3 years of age and in patients with symptoms suggestive of viral illness, e.g., cough, nasal congestion, conjunctivitis, hoarseness, diarrhea, or oropharyngeal lesions (ulcers, vesicles). One daily dose of amoxicillin for 10 days is recommended as the appropriate approach to therapy. With reassurance and educational materials from their health care provider, parents are usually agreeable to not using antibiotics, especially when presented with the information that the risks of antibiotics outweigh the benefits. Educational materials for families can be ordered from the CDC website at cdc.gov/getsmart/campaign-materials/posters.html. Texas Children’s Health Plan has CDC educational materials available for your practice and can be requested by contacting your Provider Relations representative or calling 832-828-1008 or toll-free at 1-800-731-8527. (Source: AAP Clinical 2013 Report: Principles of Judicious Antibiotic Prescribing for Upper Respiratory Tract Infections in Pediatrics (Pediatrics 2013; 132:1146-1154) Enterovirus 68: What providers need to know D r. Jeffrey Starke, infection control officer at Texas Children’s Hospital, has provided some helpful information to update you about the growing concern of Enterovirus 68. This is very useful information that you can also share with your patients and their families. The enterovirus is part of a larger family of viruses and is not new. What is new is the sudden outbreak that has occurred. It’s likely that the virus changed a little bit. As a result, kids have not been immune to it and are getting more serious symptoms than they were in the past. We aren’t sure why the outbreak has occurred, but it is not surprising that it has happened as kids went back to school. This is similar to the winter months when there is an increase in influenza cases when children return from winter break. All viruses are transmitted person-to-person and the most common way is on the hands. Good hand hygiene and proper hand washing are the most important things one can do to prevent the spread of the virus. It’s not completely clear whether this virus is spread through the air or not, but it could be the reason why it is spreading so quickly. For this virus, there is no vaccine and no particular treatment. The only way to prevent it from being transmitted to you is by practicing good hand hygiene and covering your cough. There is no reason for Houstonians to worry at this point. Normal cold and flu symptoms occur all the time. If a child has a normal cold, it is not necessary to take them to the emergency room or rush to the pediatrician’s office. If a child has a high fever for more than a couple of days, is having a difficult time keeping down fluids, and particularly if the child is having difficulty breathing, that often indicates that the child has pneumonia and parents should place a call to their child’s doctor to see if they need to come in for evaluation. T he enterovirus has been confirmed in about 10 states with a surge in respiratory infections. There have been no cases at Texas Children’s Hospital. Every day, the hospital is monitoring the number of children with respiratory infections in its pediatrics practices, emergency center, and critical care units, and there has not been an increase in patients with these symptoms. If there is an increase in the number of cases, Texas Children’s Hospital will immediately go into action to figure out what is going on and respond accordingly. 1-800-731-8527 Even though the number of children who have been infected with this virus appears to be high, the actual percentage of children infected is extremely low. 832-828-1008 TexasChildrensHealthPlan.org 9 Top over-the-counter medications prescribed in 2014 T exas Children’s Health Plan STAR members are able to obtain over-the-counter (OTC) medications at the local pharmacy in the same way they can obtain any other prescription. Providers only need to write the prescription, and the member can then obtain the OTC at their local Texas Children’s Health Plan contracted pharmacy. In 2014, the following OTC medications are the top OTC medications prescribed for our STAR members. Ibuprofen Vanacof Q-Pap Dr. Smith’s Diaper Loratadine Cetirizine Hcl Children’s Sea Soft Nasal Mist Q-Pap Children’s Loratadine Children’s Children’s Silapap Lohist-DM Oralyte Hydrocortisone Pain and Fever Children’s Lortuss DM Ibuprofen Children’s Mapap Alahist DM Infants Silapap Pediatric Electrolyte Children’s Ibuprofen Baby Ayr Saline Cetirizine Hcl Cetirizine Hcl Allergy Children’s Q-Dryl Gnp Pediatric Electrolyte Children’s Loratadine Clotrimazole Deep Sea Nasal Spray 10 TexasChildrensHealthPlan.org Getting the most value from short acting BETA agonists Harold J. Farber, MD, MSPH Associate Professor of Pediatrics, Pulmonary Section Baylor College of Medicine, Texas Children’s Hospital Associate Medical Director, Texas Children’s Health Plan M etered dose inhalers (MDIs) can feel the same and still deliver puffs long after it is no longer able to deliver a full dose of the medicine. When it “feels empty” or no longer gives a puff of medicine the inhaler has probably been empty or near empty for a while. Dose counters help the patient to know when their inhaler is empty. Of the short acting beta agonists inhalers on the Preferred Drug List (PDL), only ProAir HFA (red inhaler) has a built in dose counter. Proventil HFA (yellow inhaler) does not. Brand Name Generic Name PDL status Built in Dose Counter ProAir HFA Albuterol On PDL YES Proventil HFA Albuterol On PDL NO Xopenex HFA Levalbuterol NOT on PDL NO Ventolin HFA Albuterol NOT on PDL YES Watch for overuse. Short acting beta agonists are crisis care medicines. Frequent need for asthma symptom relief from short acting beta agonist medication is associated with an increased risk for asthma emergency department visits, hospitalizations, and death from asthma. A child whose asthma is in good control should not need more than 2 short acting beta agonist inhalers (total of 400 puffs) a year. A warning sign that asthma may be very poorly controlled is a child who is going through 4 or more short acting beta agonist inhalers (800 puffs) a year. The Center for Children and Women set to open new location The Center for Children and Women, a patient and family-centered medical home for Texas Children’s Health Plan members, is set to open its second location in Southwest Houston in November. The facility is designed to address the shortage of primary care medical needs for the Medicaid and CHIP (Children’s Health Insurance Program) populations. In-house services include behavioral health, optometry, radiology, speech therapy, and dentistry. Open 7 days a week with extended hours, patients and families can have all their medical needs met on the same day and in the same location, eliminating the need for multiple appointments. The Center for Children and Women has been recognized as a Level 3 Patient-Centered Specialty Practice for Obstetrics and a Level 3 Patient-Centered Medical Home by the National Committee for Quality Assurance (NCQA). The first Center for Children and Women facility opened in August 2013 and is located in the Greenspoint area. 832-828-1008 1-800-731-8527 New program CONNECTS members to health information T exas Children’s Health Plan has a new, comprehensive disease management program called CONNECT. The goal is to reduce the number of potentially preventable admissions, readmissions, and emergency room visits among members with select chronic diagnoses and/or co-morbid state. The program connects members to health management information through a home health nurse at a face-to-face hospital and/or home visit. Visits are followed by telephonic health coaching with the member to discuss appropriate service and resource use, disease management, and preventive care for their condition and/or co-morbidities. During these points of contact, a home visit assessment will be conducted, health education tools distributed, follow-up doctor appointments scheduled, and an individualized plan of care created. Members are encouraged to take the plan of care to their doctor upon follow-up. If, after the 4-week program, the home health nurse thinks that the member grasps how to manage their health, the program will conclude for that member. If, however, the home health nurse deems the member needs more health coaching, they will be referred to a Texas Children’s Health Plan Case Manager. Members qualifying for the CONNECT program must have 1 or more long-term diagnoses on this list: Asthma Migraine headache Attention Deficit Hyperactivity Disorder (ADHD) Seizure (epileptic) Cellulitis Sickle cell Barrier Busters offers comprehensive case review for patients A n important component of CONNECT program that is available to Primary Care Providers is called Barrier Busters. The Barrier Buster collaborative approach is a comprehensive case review for individuals who have excessive utilization patterns. The case review is held at the office of the Primary Care Provider, with all other providers (such as behavioral health, home health, therapy, and specialty providers) invited to join in person or by phone. The case managers are present as well as a Texas Children’s Health Plan associate medical director. The Ishikawa approach to identifying barriers is used to detail barriers as well as an assignment of action steps made for attending representatives. A follow-up meeting is established 4 months following the Barrier Buster to give time for use changes to occur. The health plan is responsible for sharing a comprehensive overview of use at each meeting. To refer a patient for the Barrier Buster component of the CONNECT Program, contact Deb Boggs, RN, CPHQ, Care Manager at 832-828-1284 or [email protected]. Diabetes AND have 1 of the following: 2 or more emergency room (ER) visits in 6 months 2 or more inpatient admissions in 6 months, OR 1 admission and 1 ER visit in 6 months Members are identified monthly based on medical and pharmacy claims, but can also be referred to CONNECT by: a) Practitioner referral (with a faxed order for a home health visit) b) Health Risk Assessment (completed upon enrollment to Texas Children’s Health Plan) c) Member (Self ) referral (through phone, fax, or face-to-face event) d) Utilization Management (referral from authorization activity) You will receive a fax request for home health if you have a qualifying patient. Medical home practitioners will be notified of members who qualify for the CONNECT program through a posted registry on the Texas Children’s Health Plan Provider Portal. For practitioners who do not use the online portal, a phone and/or fax connection will be made available. 1-800-731-8527 832-828-1008 TexasChildrensHealthPlan.org 11 New Texas provider marketing guidelines Further reading: You can go to our website and log-in to Provider TouCHPoint to learn more on topics like: New provider marketing rules, required by Senate Bill 8, 83rd Legislature, Regular Session, 2013, have been adopted and are in effect as of July 6, 2014. The new rules give Medicaid providers guidance about what is allowed and what is prohibited when they are marketing their services. Providers must adhere to all of the marketing guidelines. Providers are encouraged to read the guidelines carefully before marketing their services. Texas Medicaid has published the Texas Provider Marketing Guidelines at tmhp.com/Pages/ Topics/Marketing.aspx. Pharmaceutical management procedures Disease Management Programs Formulary How practitioners can access authorization criteria Limits/quotas Availability of staff to discuss authorization process Supporting an exception process Availability of TDD/TTY services Member rights and responsibilities Availability of language assistance for members Generic substitution, therapeutic interchange, and steptherapy protocol Prohibiting financial incentives for utilization management decision makers Clinical practice guidelines and preventive health guidelines The guidelines are updated on a quarterly basis and providers need to ensure they are monitoring for updates and changes. Texas Children’s Health Plan continues to implement and enforce correct coding initiatives. for all claims In compliance with Texas Medicaid Healthcare Partnership (TMHP) and Centers for Medicare & Medicaid Services (CMS) guidelines, Texas Children’s Health Plan implemented the CMS National Correct Coding Initiative (NCCI) and Mutually Exclusive Edit (MUE) guidelines effective April 1, 2011 for dates of service on or after October 1, 2010. All claims must be filed in accordance with these guidelines, including services that have been prior authorized with medical necessity documentation. The CMS NCCI and MUE guidelines can be found in the NCCI Policy and Medicare Claims Processing manuals, which are available at the CMS website at http://www.cms.gov/Medicare/ Coding/NationalCorrectCodInitEd/index. html?redirect=/National CorrectCodinitEd. Edit files are available to the public on the Medicaid TexasChildrensHealthPlan.org Referrals to case management NCCI webpage on the Medicaid.gov website. Typically, CMS posts the edit files for the public on the Medicaid NCCI webpage on the first day of the calendar quarter. CMS NCCI and MUE guidelines 12 Quality program goals, processes, and outcomes Note: Providers are required to comply with NCCI and MUE guidelines as well as the guidelines that are published in the Texas Medicaid Provider Procedures Manual and Children with Special Health Care Needs (CSHCN) Services Program Provider Manual. condition for reimbursement, it is not a guarantee of payment. If a provider appeals a previously processed claim, then the NCCI edit rules will apply and claims will be subject to the guidelines. Providers with questions or comments on the NCCI and MUE guidelines are encouraged to contact their professional societies for clarification. For additional information, providers are encouraged to refer to the TMHP NCCI Compliance web page at: http://www.tmhp.com/Pages/CodeUpdates/ NCCI.aspx. In instances where the Texas Medicaid medical policy is more restrictive than the NCCI or MUE guidance, Texas Medicaid or CSHCN Services Program medical policy prevails. If a rendered service does not comply with a guideline as defined by NCCI, medical necessity documentation may be submitted with the claim for service to be considered for reimbursement. However, medical necessity documentation does not guarantee payment for these services. Important: Prior authorization and authorization based on documentation of medical necessity is a 832-828-1008 1-800-731-8527 PROVIDER NEWS Provider News is published quarterly by Texas Children’s Health Plan. © 2014 Texas Children’s Health Plan All rights reserved. P.O. Box 301011, NB 8301 Fall 2014